29 - Implementing Trauma-Informed Care in the Provision of Pediatric Speech-Language Pathology Services

Abstract: It is widely accepted that the development and health of children will be negatively impacted if exposed to adverse childhood experiences (ACE). Communication is among the developmental areas negatively impacted by ACE. Trauma-informed care (TIC) is a strength-based approach that decreases the impact of trauma on one’s system. This poster provides an overview of TIC and how to implement TIC in the provision of pediatric speech-language pathology services. It describes research in support of TIC including how our brain and nervous system are impacted negatively by adverse experiences and positively by resiliency. It discusses how behaviors are driven by our brain’s need for safety and connection. Lastly, it describes five trauma-informed strategies SLPs can implement during provision of SLP services.

Description: It is widely accepted that development and health of children will be negatively impacted if exposed to adverse childhood experiences (ACE). The earlier the exposure, and the greater the number of adverse experiences, the larger the impact will be on development and health (Anda et al., 2006). Communication is among the developmental areas negatively impacted by ACE (Rupert & Bartlett, 2021).

Trauma occurs when ACE create excessive stress, overwhelming a person’s ability to cope. Trauma-informed care (TIC) is a strength-based approach implemented to decrease impact of trauma on one’s system by facilitating resiliency and, thus, enabling recovery from adverse experiences (Gayaldo & Gladfelter, 2022). SLPs need to increase our understanding of TIC, the theory and research behind TIC, and implementation of TIC during the provision of pediatric SLP services (O’Leary, Rupert, & Lotty, 2023; Roberson & Lund, 2022).

Purpose
This poster describes strategies for implementing TIC in the provision of pediatric SLP services. The poster discusses a framework developed by the non-profit organization Community Resilience Initiative (CRI), which provides training in TIC nationally and internationally. The poster reviews research supporting TIC, including how our brain and nervous system are impacted negatively by adverse experiences and positively by resiliency. The poster discusses how behaviors are driven by our brain’s needs for safety and connection, and the poster provides five trauma-informed mini-strategies SLPs can implement when providing intervention for children exposed to ACE.

NEAR Sciences
The acronym NEAR provides the rationale supporting TIC.
Neuroscience
Neuroscience helps us understand biological and physiological mechanisms underlying the effects of trauma on our brains and body. Throughout evolution, our brain has predicted and responded to threats to keep us safe. When the brain’s threat prediction is activated, the body responds with fight, flight or freeze, and releases chemicals facilitating survival and safety. When the brain predicts positive experiences, the body responds with social engagement and resilience, and releases different chemicals facilitating feelings of reward and safety.

Epigenetics
Epigenetics suggests environmental experiences affect how genes are expressed or silenced through epigenetic mechanisms. Epigenetics suggests we can change our ways of acting and can help change how others act.

ACE Studies
Adverse experiences can result in brain changes from chemicals released within our threat response system. The ACE study (see Anda, et al., 2006) paved the way for developing TIC and strategies to prevent and change the outcomes of ACE.

Resilience
Resilience occurs when brains are rewired to predict safety rather than threats by changing the way the brain processes information and responds to stress. Positive relationships increase positive safety predictions and enhance resilience. Threat predictions cause resilience to decrease.

The Brain and Behaviors
The primary mission of the brain is sustaining optimal bodily functions to survive. The brain continually collects sensory data from the environment to predict whether a situation is a threat or resource based on past experiences. If a situation is predicted as a threat, the behavior demonstrated is flight, fight or freezing. If a situation is predicted as a resource, the behavior demonstrated is connecting socially.

Behavior Development
Behavior development is based on our brain’s wiring to survive. Brains use behaviors to communicate our needs. For example, we eat when hungry. When the need is met, e.g., we eat and are no longer hungry, that behavior is no longer needed and turns off.

Don’t Judge
Behaviors are complex and diverse and, as such, SLPs don’t know what behavior has been put in place to meet the brain’s survival needs. SLPs should be sensitive, empathetic, and curious about the underlying needs of our child’s behaviors but not judgmental.

Strategies to Respond to Trauma: ROLES
The acronym ROLES, developed by CRI, consists of five trauma-informed mini strategies, which can be implemented by SLPs, to provide TIC for children exposed to ACE.

Recognize and Respond to Our Own Predictions
The recognize mini strategy consists of two parts. First, SLPs assess our own emotional and mental state to avoid projecting negative emotions on others. Next, we have an actionable plan to regulate our emotional state if needed. We recognize what types of communication we use at different levels of threat we experience in our environment– mild, moderate, high, life threatening.

Observe the External Behavior that is Communicating the Internal Prediction
The observe mini strategy also consists of two parts. First, SLPs observe external behaviors to gauge the child’s internal state and what their brain predicts about the environment. Then, we learn, over time, what behavioral responses the child uses at different levels of threat – mild, moderate, high, life threatening. This helps us anticipate their reactions in different situations.

Label the Actual Communication Attempts You Observe
The label mini strategy reduces feelings of judgement and helps link internal emotional states to external behaviors. SLPs must use “no judgement” labeling of behaviors and not use “hard” or “soft” judgement labels. Examples of no judgement labeling include “Your shoulders are up, like this…” and “And your face is going like this… What’s going on?”

Electing Positive Intent Helps Continue Safety Predictions
The electing mini strategy involves the SLP choosing positive intent to interpret the child’s behaviors and actions. The SLP diminishes their lens of judgement and bias and sets aside preconceived notions and biases.

Solve by Using Strategies to Address the Child’s Need
The solve mini strategy uses a variety of strategies that best address the specific child’s needs. The purpose is to reallocate the brain’s resources from immediate survival needs triggered by threat predictions to use of higher cognitive functions allowing meaningful engagement, learning, and planning.

Conclusion
Trauma-informed strategies are similar to strategies SLPs implement when providing services for children with communication challenges. They include self-reflection about our services, behavioral observations of the child, labeling the child’s behaviors objectively and positively, and creating meaningful communication exchanges utilizing the child’s communication strengths. While familiar strategies for SLPs, the outcome is multifaceted. In addition to building effective communication skills, we are also meeting the child’s needs for safety and connection and are building resiliency for children exposed to ACE.

Supporting Research: Reference 1: Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., Dube, S. R., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–186. 10.1007/s00406-005-0624-4

Supporting Research: Reference 2: Gayaldo, S. & Gladfelter, A. (2022). Prevalence versus evidence: A closer look at the research available for serving children exposed to maltreatment and a response to Hyter’s call for trauma-informed care. American Journal of Speech-Language Pathology, 31, 2283-2288. https://doi.org/10.1044/2022_AJSLP-21-00380

Supporting Research: Reference 3: O’Leary, N., Rupert, A.C., & Lotty, M. (2023). Understanding the why: The integration of trauma-informed care into speech and language practice. Advances in Communication and Swallowing, 26, 81-87. https://doi.org/10.3233/ACS-220017

Supporting Research: Reference 4: Roberson, M. M. & Lund, E. (2022). School-based speech-language pathologists’ attitudes and knowledge about trauma-informed care. Language, Speech, and Hearing Services in Schools, 53, 1117-11128. https://doi.org/10.1044/2022_LSHSS-21-00172

Supporting Research: Reference 5: Rupert, A.C. & Bartlett, D.E. (2021). The childhood trauma and attachment gap in speech-language pathology: Practitioners’ knowledge, practice, and needs. American Journal of Speech-Language Pathology, 31, 287-302. https://doi.org/10.1044/2021_AJSLP-21-00110